New Patient Information
Dr. Ronald G. Peterson Jr. D.C.
Dianna L Becherer LMT
Demographic Information
Name ________________________________________________
Date of Service _____________
Address ______________________________________________
Phone: (H) ________________
City _____________________________State ______ Zip ______
(W) ________________
E-mail _______________________________________________
Marital Status S M D W
Date of Birth _______________ (Age ______)
Occupation ___________________________________
Employer________________________________
Spouse’s Name ________________________________
Spouse’s Occupation _______________________
Emergency Contact _____________________________________________________________
Name
Phone #
Relationship
When doctors work together it benefits you. May we have your permission to update your medical doctor
regarding your care at this office?
Y
N
Primary Care Physician ______________________________________________________________________
Name
Address
Phone #
How did you hear about Peterson Health Clinic LLC.? ________________________________________
Please check any and all insurance coverage that may be applicable in this case:
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Major Medical
Worker's Compensation
Medicare
Auto Accident
Medical Savings Account & Flex Plans
Other
__________________________________________
Signature
___________________
Date
815 Lincoln Hwy, Suite 101
Fairview Heights, IL 62208
PH: 618.589.3911
FAX: 618.589.3912
E-mail us at: petersonhealthclinic@yahoo.com Visit us at: petersonhealthclinic.com
Chiropractic Case History/Patient Information
What type of regular exercise do you perform?
Height ____ft____in
None
Weight ______lbs
Some Moderate
Strenuous
For each of the conditions listed below, place a check in the Past Column if you
have had the condition in the past. If you presently have the condition place
a check in the present column.
Past
Present
Past
Present
Past
Neck Pain
Upper Back Pain
Mid Back Pain
High Blood
Pressure
Heart Attack
Chest Pains
Stroke
Low Back Pain
Angina
Shoulder Pain
Kidney Stones
Headache
Elbow/Upper Arm
Pain
Wrist Pain
Hand Pain
Hip/Upper Leg Pain
Knee/Lower Leg
Pain
Ankle/Foot Pain
Jaw Pain
Joint
Swelling/Stiffness
Present
Chronic Sinusitis
Diabetes
Excessive Thirst
Frequent Urination
Smoking/Use
Tobacco
Drug/Alcohol
Dependence
Kidney Disorders
Allergies
Bladder Infection
Painful Urination
Loss of Bladder
Control
Depression
Systemic lupus
Prostate Problems
Abnormal Weight
Gain/Loss
Loss of Appetite
Epilepsy
Dermatitis/Eczema/
Rash
HIV/Aids
Females Only
Abdominal Pain
Birth Control Pills
Arthritis
Ulcer
Hormonal
Replacement
Rheumatoid
Arthritis
Hepatitis
Pregnancy
General Fatigue
Liver/gall Bladder
Disorder
Muscular incoordination
Visual Disturbances
Dizziness
Other
Cancer
Tumor
Asthma
Indicate if an immediate family member has had any of the following:
Rheumatoid Arthritis
Heart Problems
Diabetes
Cancer
Lupus
List all prescriptions, over-the-counter medications, and nutritional supplements you are taking:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
List all of the surgical procedures you have had and times you have been hospitalized:
____________________________________________________________________________________________________________
__________________________________________________________________________________________
Patient Signature__________________________________ Date__________________________
Please read thoroughly, INITIAL at each section
Cancellation Policy
_________ 24 hour notice is required if you have to cancel your appointment, otherwise the full treatment price
will be charged. Thank You.
Information about Possible Risk of Treatment
_________ You have the right, as a patient, to be informed about your condition and the recommended
integrative and complementary procedure to be used so that you make an informed decision whether or not to
undergo the procedure after knowing the risks and hazard involved. This disclosure is not meant to scare or
alarm you; it is simply an effort to make you better informed so you may give or withhold your consent to the
procedure.
Doctors of Chiropractic, Medical Doctors, Massage Therapists and Physical Therapists using manual
therapy treatment for patients with headaches and cervical spine (neck) complaints are required to explain that
there have been rare cases of injury to a vertebral artery as a result of treatment. Such an injury has been known
to cause a stroke, sometimes with serious neurological damage. The rare chance of this happening is estimated
to be approximately 1 per 10 million treatments. Appropriate tests will be performed to help identify if you
may be susceptible to this type of injury; you will be notified if that is the case. If you have any questions about
this, please do not hesitate to speak with your practitioner.
As with any health care procedure, complications may arise during treatment. These complications
include soreness, muscle or ligament sprain/strain, dislocation, fractures, disc injuries or physiotherapy burns.
These are extremely rare occurrences.
Consent for Treatment
_________ I authorize the performance of diagnostic tests, procedures and treatment deemed necessary by
personnel involved in my care.
Authorization to Treat a Minor (under the age of 18)
I hereby request and authorize my doctor at this clinic to perform diagnostic tests and render chiropractic
adjustment and other treatment to my minor son/daughter. This authorization also extends to include
radiographic examination at the doctor’s discretion. As of this date, I have legal right to select and authorize
health care services for the minor child named above. Under the terms and conditions of my divorce (if
applicable), separation or other authorization, the consent of a spouse/former spouse or other parent is not
required. If my authority to so select and authorize this care should be revoked or modified in any way, I will
immediately notify Peterson Health Clinic LLC.
______________________________________________________________________________
Signature of Patient or Responsible Party
Date
Relationship to Patient
Usual and Customary Rates
______Peterson Health Clinic LLC is committed to providing the best care for our patients and we charge
what is usual and customary for our area. You are responsible for payment regardless of any insurance
company’s arbitrary determination of usual and customary rates.
Assignment of Insurance Proceeds
_______If you have insurance, please sign this assignment of benefits agreement.
By agreeing to this
assignment, we will direct your insurance company to make any payments for your chiropractic, physiotherapy,
physical rehabilitation, diagnostic testing, or any other reimbursable treatment or evaluations you receive to our
clinic directly.
In exchange for services and supplies rendered, I do assign to Peterson Health Clinic LLC., any insurance
proceeds, including accident and health insurance benefits and bodily injury claim awards up to the amount of
any unpaid balance with interest as allowed by law.
Records Release Authorization
_______You, Peterson Health Clinic LLC. are authorized to release any information contained in my file
to any insurance company, attorney, adjuster or member of my office staff, including any contracted billing
services representing the clinic, in order to process any claim for reimbursement of charges incurred for
supplies furnished to me or services rendered to me by you or another member of the clinic. I further
authorize phone contact with the above listed third parties, should phone contact be required for the purpose
of obtaining payment for charges outstanding.
Patient Acknowledgement and Receipt of Notice of Privacy Practices
Pursuant to HIPAA and Consent for Use of Health Information
The patient understands and agrees to allow this chiropractic office to use their Patient Health Information for
the purpose of treatment, payment, healthcare operations, and coordination of care. We want you to know how
your Patient Health Information is going to be used in this office and your rights concerning those records. If
you would like to have a more detailed account of our policies and procedures concerning the privacy of your
Patient Health Information we encourage you to read the HIPAA NOTICE that is available to you at the front
desk before signing this consent.
The undersigned does hereby acknowledge that he or she has received a copy of this office’s Notice of Privacy
Practices Pursuant To HIPAA and has been advised that a full copy of this office’s HIPAA Compliance Manual
is available upon request.
The undersign does hereby consent to the use of his or her health information in a manner consistent with the
Notice of Privacy Practices Pursuant to HIPAA, the HIPAA Compliance Manual, State law and Federal Law.
______________________________________
Name (Printed please)
_________________________________________
Signature
Date
If you are a minor, or if you are being represented by another party:
_______________________________________
Personal Representative Printed
______________________________________________
Description of the authority to act on behalf of the patient.
_________________________________________
Personal Representative Signature
Date
Peterson Health Clinic
FINANCIAL POLICY
Our recommendations are based on a desire to see you get well and stay well. Chiropractic care is covered under
many insurance plans. Most of our patients that have health or accident insurance will fall under one of the plans
discussed in this policy. Regardless of your coverage, we’ll suggest the chiropractic care we think you need. We
ask that you read and understand our policy as it applies to your particular situation.
PATIENTS WITHOUT INSURANCE
We request that 100% of the first visit be paid at the time of the visit. On other visits, payment may be made at the end of
the week if you sign a credit guarantee form. We are happy to accept your check, Master Card or Visa.
GROUP OR INDIVIDUAL INSURANCE
Your insurance is an agreement between you and your insurance company, not between your insurance company and our
office. We cannot be certain if your insurance covers Chiropractic, although most policies do provide coverage. The
amount they pay varies from one policy to another. When possible, we will call to verify benefits on your insurance;
however, the benefits quoted to us by your insurance company are not a guarantee of payment. As a courtesy to you, our
office will complete any necessary insurance forms at no additional charge, and file them with your insurance company to
help you collect. It is to be understood and agreed that any services rendered are charged to you directly and you are
personally responsible for payment of any non-covered services, deductibles or co-pays. You may also pay the full
amount due each day thereby qualifying for our Time of Service Reduction in fees. You may then submit the bill to your
insurance carrier for reimbursement.
“ON THE JOB” INJURY (Worker’s Compensation)
If you are injured on the job, your care should be paid for under your employer’s Worker’s Compensation insurance. You
will need to inform your employer of the accident and obtain the name and address of the carrier of their insurance. If
your employer does not provide us with this information, if a settlement has not been made within 3 months, or if you
suspend or terminate care, any fees and services are due immediately.
PERSONAL INJURY OR AUTOMOBILE ACCIDENTS
Please present your auto insurance card, your health insurance card, and tell us if you have retained an attorney. There are
four options available to the PI patient:
1. Pay cash for your care and we will submit reports whenever necessary.
2. We will bill (accept assignment) from the Med Pay portion of your auto insurance.
3. We will accept a Letter of Protection or Doctor’s Lien from an attorney and await payment at the time of
settlement as long as you remain an active patient.
4. We will bill your standard health insurance plan and you will be responsible for all co-pays and deductibles as
they are incurred.
Although you are ultimately responsible for your bill, we will wait for settlement of your claim for up to six months after
your care is completed. Once the claim is settled or if you suspend or terminate care, any fees for services are due
immediately.
MEDICARE
We do accept assignment from Medicare. The check is usually sent directly to our office in payment of the services that
Medicare will cover which for Chiropractors is ONLY manual manipulation of the spine. Medicare pays 80% of the
allowable fee once the deductible has been met. You are required to pay the deductible and the remaining 20%. All other
services we provide are NON-COVERED. These services include, but are not limited to, x-rays, examinations, therapies,
orthotics, supports, and/or nutritional supplements. Medicare patients are fully responsible for charges of non-covered
services. Secondary insurance may or may not pay for these non-covered services. Our office completes and files the
forms for Medicare at no charge.
SECONDARY INSURANCE
Please inform us of any secondary insurance you may have. We will assist you if you need help in filing.
FLEX PLANS/MEDICAL SAVINGS ACCOUNTS
Please inform us if you have a medical savings account, sometimes known as a 'flex plan'. We will be happy to provide
you with a statement of your charges for reimbursement.
INSURANCE FORMS/PAYMENT
Occasionally, either by mistake, or due to provisions in your policy, the check issued by the insurance company for
payment of services rendered in our office, may come to you instead of our office. If you should receive any unexpected
check in the mail, please contact us to see if it does represent payment of your bill here.
I have read and understand the payment policy of Peterson Health Clinic. I understand that my insurance is an
arrangement between myself and my insurance company, NOT between Peterson Health Clinic and my insurance
company. I request that Peterson Health Clinic prepare the customary forms at no charge so that I may obtain insurance
benefits. I also understand that if my insurance does not respond within 60 days, or if I suspend or terminate my schedule
of care as prescribed by the doctors at Peterson Health Clinic that fees will be due and payable immediately.
____________________________________________________________
Patient’s signature (or guardian if patient is a minor)
Date